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How Does Direct Primary Care Work?

Direct primary care practices serve as a patient’s “primary care medical home” (D-PCMH) where they go for all routine primary, preventive and chronic care management types of care. Patients pay one low monthly fee-sometimes as low as $75-directly to their direct primary care facility for all of their everyday health needs. Like a health club membership, this fee gives patients unrestricted access for visits and care, so patients can use the services as much or as little as they want. Many direct primary care practices are open seven days per week and offer same-day or next-day appointments. At many clinics, physicians are on call 24/7.

There is none of the paperwork and expense required today by insurance reimbursement – no procedure or billing approval, deductibles or co-payments. With a lower business overhead and dramatically less paperwork, primary care providers are no longer forced to squeeze in an unmanageable number of patients and can instead take the time necessary with each patient to deliver high-quality, personalized care.

Accidents and the unexpected do happen, so the typical patient in a direct primary care practice keeps an insurance plan to cover emergencies and serious illnesses. Because this insurance doesn’t need to cover routine care, many patients choose a less comprehensive plan with a higher deductible and lower premium.

Lower costs

With insurance-paid primary care, where each and every part of your medical care is billed to a third party payer, reimbursement costs consume more than 40 cents of each dollar. Eliminating insurance from primary care makes that 40 cents available for actual health care – more time with each patient, more extensive office hours, more on-site services and diagnostics, and more patient-provider support technology.

Patients Save

The combined cost of the primary care provider monthly fee and a lower-premium insurance plan is significantly lower than paying for soup-to-nuts health insurance that covers even basic primary care needs. This is important when more than three-quarters of America’s uninsured are working families. The annual income from a full-time minimum wage job is only a few hundred dollars more than the cost of an average family insurance plan. With direct primary care, supported by a low-premium “wrap-around” insurance plan that covers everything primary care facilities do not, cost to families can drop by as much as 50%, saving hundreds or even thousands annually.

Employers save

Even with a combination of direct primary care membership and lower-cost “wrap-around” insurance policies, employers opting for this combined option have routinely saved 20 to 35 percent on comprehensive health care benefits over what they currently spend, while employees’ payments (including premium cost-sharing, deductibles, co-payments and co-insurance) drop significantly. Downstream savings from unnecessary diagnostics and specialist, hospital and/or emergency room care add to these savings. In states where workers compensation insurance premiums are based on claims history, employers may be able to significantly reduce their costs as direct primary care practices do not file insurance claims, even though they do complete any legally required paperwork. Many employers also appreciate the impact that high accessibility direct primary care practices have on lowering absenteeism and improving patient health.

Higher-quality care

By eliminating unnecessary insurance costs, we also eliminate the need for primary care providers to flood their practices with thousands of patients that require reams of paperwork. A smaller patient pool allows primary care providers to spend more time with each patient. Instead of being rushed through a 5 or 10 minute appointment on what feels like a conveyer belt, patients are allocated what each needs (even if it is an hour or more) to discuss health details with doctors or nurse practitioners. There is time to actually treat, not just get an overview then refer to an expensive outside specialist. Most Americans have never experienced this level of care. For patients with chronic illnesses such as diabetes or high blood pressure, the unrestricted access to a primary care physician can have dramatic, often life-changing, effects on the individual’s health. As a result, doctor visits are no longer restricted by bank accounts and patients are seeing their providers whenever necessary to manage their health issues and improve their quality of life.

Reinvigorating Primary Care

By eliminating insurance burdens from direct primary care practices, physicians, nurse practitioners and physician assistants have more time to do what they were trained to do – practice medicine. This allows direct primary care practices to serve as a patient’s “medical home.” They develop deep, personal relationships with their patients and have ample time to diagnose and treat underlying problems. Providers can get off the treadmill of seeing 25 to 35 patients a day (national average for insurance-based practices), providing a balanced life-style. Physicians act based on what is in their patients’ best interests rather than those of the insurance company. Direct primary care can stave off the exodus from primary care that has been occurring over the past decade:

  • Many former primary care physicians who discover this model actually return to primary care.
  • Medical students are once again selecting primary care as their career of choice.
  • Primary care physicians discover that with this model they no longer need to retire early to escape the stress of insurance-based primary care.

Why is it Better? The Direct Primary Care Difference

To understand why membership-based direct primary care offers better solutions, it’s important to first understand the difference between primary care and specialist/hospital care:

Primary care should be the home base or “medical home” for your health care. Your primary care provider is responsible for your overall wellness. Any time you have a health concern, your first visit should be to your primary care provider, who knows all of your medical history and can help you make the best decision about your health. With most health issues, your primary care provider can diagnose and heal the problems you’re experiencing.

Specialist and hospital care should be for serious, complex illnesses and life-threatening emergencies. If you’re severely injured in an accident, for example, an ambulance takes you to the emergency room. Or, if you’re diagnosed with cancer, you may need hospital care such as surgery, radiation, or other treatments.

Insurance is an important part of specialist and hospital care. Similar to automobile insurance, our health insurance system was originally designed to pay for rare, unpredictable, and extremely expensive problems. It is essential when patients need emergency care or an operation and chemotherapy treatments, care provided by specialists and hospitals.

Primary care is frequent, highly predictable, and relatively inexpensive. It doesn’t make sense to pay for primary care using insurance. Paying for primary care with insurance has caused the cost of primary care and the downstream specialist/hospital care to rise considerably, and has made health care cost-prohibitive for millions of Americans.

Direct primary care practices eliminate insurance overhead, which can extend health care to more Americans.

Healthier patients

Direct primary care enables doctors and nurses to provide better care for patients. Unlimited visits and a smaller patient pool mean patients get more time with providers. Without unnecessary co-pays and referrals there is greater continuity of care, which means better, more informed decisions about a patient’s health.

Happier providers

Primary care has been a victim of the health care crisis.

Family health practices across the nation are closing because they can’t stay financially afloat.

Whereas 50 percent of medical students once chose primary care as a profession, that percentage is now in the single digits. This migration is fueled by growing dissatisfaction with the insurance-laden business models in primary care that make specialization options more attractive, due to less paperwork and increased income.

The result? The average primary care office visit “face time” is now seven minutes and rarely longer than 15 minutes. In order to see the 25-35 patients in person per day required to sustain a traditional clinical practice, providers must manage between 2,500 and 3,500 regular patients. Contrast this with a busy day for a direct primary provider, containing about half the number of office appointments, providing doctors ample time to examine patients and explore diagnosis and treatment options, preferences, concerns and fears. Additionally, providers are not tied to insurance reimbursement requirements of in-person visits so they can be flexible and offer phone and/or secure email consultations if it’s more convenient for the patient and appropriate to the kind of care needed.

Providers report increased satisfaction and renewed commitment to provide the kind of care that initially inspired them to dedicate their lives to medicine. In short, direct primary care facilities enable physicians and nurses to do what they felt called to do: treat patients.

“With traditional insurance models, providers are forced to view people with health issues as a collection of symptoms. In a Direct Primary Care practice I get to develop a therapeutic relationship with patients. This relationship allows me to understand the patient’s context, i.e. who they are not only physically, but socially, emotionally, and mentally. I am able to take the time to find out what’s important to them and what their barriers to wellness are. This is the accurate definition of health care.”

~ Lynne Duran,
ARNP, Family Nurse Practitioner

The bottom line: Doctors and nurses have less burden and are free to focus on patients, not paperwork.